Showing papers by "Stuart J. Head published in 2017"

Current Practice of State-of-the-Art Surgical Coronary Revascularization.

Abstract: Coronary artery bypass grafting remains one of the most commonly performed major surgeries, with well-established symptomatic and prognostic benefits in patients with multivessel and left main coronary artery disease. This review summarizes current indications, contemporary practice, and outcomes of coronary artery bypass grafting. Despite an increasingly higher-risk profile of patients, outcomes have significantly improved over time, with significant reductions in operative mortality and perioperative complications. Five- and 10-year survival rates are ≈85% to 95% and 75%, respectively. A number of technical advances could further improve short- and long-term outcomes after coronary artery bypass grafting. Developments in off-pump and no-touch procedures; epiaortic scanning; conduit selection, including bilateral internal mammary artery and radial artery use; intraoperative graft assessment; minimally invasive procedures, including robotic-assisted surgery; and hybrid coronary revascularization are discussed.

Adverse events while awaiting myocardial revascularization: a systematic review and meta-analysis

Abstract: OBJECTIVES The aim of the current study was to estimate adverse event rates while awaiting myocardial revascularization and review criteria for prioritizing patients. METHODS A PubMed search was performed on 19 January 2015, to identify English-language, original, observational studies reporting adverse events while awaiting coronary artery bypass grafting (CABG) or percutaneous coronary intervention (PCI). Rates of death, non-fatal myocardial infarction (MI) and emergency revascularization were calculated as occurrence rates per 1000 patient-weeks and pooled using random-effects models. RESULTS The search yielded 1323 articles, of which 22 were included with 66 410 patients and 607 675 patient-weeks on the wait list. When awaiting CABG, rates per 1000 patient-weeks were 1.1 [95% confidence interval 0.9-1.3] for death, 1.0 [0.6-1.6] for non-fatal MI and 1.8 [0.8-4.1] for emergency revascularization. Subgroup analyses demonstrated consistent outcomes, and sensitivity analyses demonstrated comparable event rates with low heterogeneity. Higher urgency of revascularization was based primarily on angiographic complexity, angina severity, left ventricular dysfunction and symptoms on stress testing, and such patients with a semi-urgent status had a higher risk of death than patients awaiting elective revascularization (risk ratio at least 2.8). Individual studies identified angina severity and left ventricular dysfunction as most important predictors of death when awaiting CABG. Adverse rates per 1000 patient-weeks for patients awaiting PCI were 0.1 [95% confidence interval 0.0-0.4] for death, 0.4 [0.1-1.2] for non-fatal MI and 0.7 [0.4-1.4] for emergency revascularization but were based on only a few old studies. CONCLUSIONS Rates of death, non-fatal MI and emergency revascularization when awaiting myocardial revascularization are infrequent but higher in specific patients. Countries that not yet have treatment recommendations related to waiting times should consider introducing a maximum to limit adverse events, particularly when awaiting CABG.

Influence of practice patterns on outcome among countries enrolled in the SYNTAX trial: 5-year results between percutaneous coronary intervention and coronary artery bypass grafting

Abstract: OBJECTIVES: To examine differences among participating countries in baseline characteristics, clinical practice, medication strategies and outcomes of patients randomized to coronary artery bypass grafting and percutaneous coronary intervention in the SYNTAX trialMETHODS: In SYNTAX, centres in 18 different countries enrolled 1800 patients, of which 8 countries enrolled ≥80 patients, what was projected to be a large enough sample size to be included in the analysis Baseline characteristics, practice patterns and clinical outcomes were compared between the USA (n = 245), the UK (n = 267), Italy (n = 197), France (n = 208), Germany (n = 179), Netherlands (n = 148), Belgium (n = 91) and Hungary (n = 83) The remaining patients from other participating countries were pooled together (n = 382)RESULTS: Five-year results demonstrated significantly different outcomes between countries After adjustment, percutaneous coronary intervention patients in France had lower rates of major adverse cardiac and cerebrovascular events [hazard ratio (HR) = 060, 95% confidence interval (CI) 037-098], while the incidence of repeat revascularization was higher in Hungary (HR = 189, 95% CI 114-342) Coronary artery bypass grafting showed the lowest rate of repeat revascularization in the UK (HR = 032, 95% CI 012-085) There were numerous differences in the risk profile of patients between participating countries, as well as marked differences in surgical practice across countries in the use of blood cardioplegia (range 31-890%; P < 0001), bilateral internal mammary artery usage (range 78-682%; P < 0001) and off-pump procedures (range 39-444%; P < 0001) Variation was also found for percutaneous coronary intervention in the number of implanted stents (range 40 ± 23 to 61 ± 26; P < 0001) as well as for the entire stents length (range 690 ± 451 to 1241 ± 609; P < 0001) Remarkable differences were observed in the prescription of post-coronary artery bypass grafting medication in terms of acetylsalicylic acid (range 796-950%; P = 0004), thienopyridine (68-311%; P < 0001) and statins (413-891%; P < 0001)CONCLUSIONS: Patient characteristics and clinical patterns are significantly different between countries, resulting in significantly different 5-year outcomes This article presents specific data that can further improve outcomes in each countryClinical Trials Registry: NCT00114972

A meta-analysis on clinical outcomes after transaortic transcatheter aortic valve implantation by the Heart Team.

Abstract: Aims We aimed to perform a meta-analysis on transaortic (TAo) transcatheter aortic valve implantation (TAVI) in order to gain more insight into the safety and efficacy of the approach in addition to the data available from selected centres with small numbers of patients. Methods and results PubMed and EMBASE were searched on 31 August 2016. The search yielded 251 studies, of which 16 with 1,907 patients were included in the meta-analysis. All were observational, single-arm studies. The rate of conversion to sternotomy was 3.2% (95% CI: 2.3-3.5%; I2=0) among nine studies. Device success among 10 studies was 91% (95% CI: 86.7-94.0%; I2=25.5). Major vascular complications occurred at a rate of 3.1% (95% CI: 1.6-6.0%; I2=60.8). Moderate or severe paravalvular leakage/aortic valve regurgitation (PVL/AR) was reported to be 6.7% (95% CI: 4.3-10.1%; I2=58.9). Permanent pacemaker implantation was required in 11.7% (95% CI: 9.2-14.8%; I2=26.5) of patients. Pooled 30-day post-TAVI complication rates were 9.9% (95% CI: 8.6-11.3%; I2=0) for mortality, 3.7% (95% CI: 2.4-5.6%; I2=28.7) for all stroke, and 1.0% for myocardial infarction (95% CI: 0.5-1.7%; I2=0). The Valve Academic Research Consortium-2 (VARC-2) composite safety endpoint occurred at a pooled rate of 16.7% (95% CI: 10.6-25.3%; I2=58.7). Conclusions In this meta-analysis of observational studies, transaortic TAVI appears to be a safe procedure with low complication rates.

Hierarchical testing of composite endpoints: applying the win ratio to percutaneous coronary intervention versus coronary artery bypass grafting in the SYNTAX trial.

Abstract: Aims: The goal of the study was to compare long-term outcomes of percutaneous coronary intervention (PCI) versus coronary artery bypass grafting (CABG), accounting for the clinical impact of individual components in the composite endpoints and prioritising these using the win ratio (Rw). Methods and results: The win ratio was compared with conventional methods of analyses (hazard ratio [HR] and relative risk) in the SYNTAX trial (n=1, 800). For the composite of death/stroke/myocardial infarction (MI), the win ratio favoured CABG and was 1.37 (95% CI: 1.10-1.77) for matched analysis, 1.28 (95% CI: 1.11-1.53) for unmatched analysis, while the conventional HR was 1.29 (95% CI: 1.11-1.53). The largest number of winners in favour of CABG over PCI were based on MI (n=39 vs. n=19, respectively). Death was significantly reduced with CABG in matched (Rw=1.39, 95% CI: 1.04-1.86) and unmatched win ratio analyses (Rw=1.27, 95% CI: 1.01-1.42) as compared with non-significant conventional analysis (HR 1.19, 95% CI: 0.92-1.56). In subgroups, matched win ratio analyses had a larger treatment effect in favour of CABG compared with conventional analyses, especially in patients with three-vessel disease and intermediate SYNTAX scores, while unmatched win ratios had a smaller point estimate, but with narrower confidence intervals than matched analyses findings. Conclusions: This re-analysis of the SYNTAX trial using the win ratio shows that the most important benefit of CABG treatment is the reduction of hard clinical endpoints such as mortality and MI. Future trials using this approach can expect to maintain similar statistical power with smaller sample sizes, and thereby reduce the cost of a trial. ClinicalTrials.gov Identifier: NCT00114972.